Future-proofing diabetes foot services in remote and rural health settings post COVID-19
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Article
Future-proofing diabetes foot services
in remote and rural health settings
post COVID-19
Sandra Jones and Sandra MacRury
Citation: Jones S, MacRury S This article discusses how a remote and rural Scottish health board has adapted, and
(2021) Future-proofing diabetes
foot services in remote and rural continues to adapt, to delivering multidisciplinary diabetes foot services. The COVID-19
health settings post COVID-19. The pandemic has exacerbated the challenges that were already experienced on a daily basis
Diabetic Foot Journal 24(2): 1–6
and has encouraged the podiatry team and the multidisciplinary diabetes foot team to
Key words innovate and advance the service delivery options.
T
- Accessibility
- Service pathways he diverse rural terrain of the Scottish Rurality
- Remote and rural Highlands presents challenges in delivering Rural area classification across Scotland is based
- Skilled workforce
- Team working,
services, including a difficult landscape, upon two main criteria: population, as defined by
- Technology enhanced rugged coastlines, many remote and rural areas, National Records of Scotland, and accessibility,
care and learning inhabited islands, limited transport and poor based on drive time analysis to differentiate between
communications infrastructure. accessible and remote areas in Scotland (Scottish
Article points
The Highland Health Board covers an area >40% Government 2018a; Figure 2).
1. The Highland Health Board
is one of the largest and
of the Scottish land mass and is spread over 32,500 There are higher costs associated with the larger
most sparsely populated km2, making it one of the largest and most sparsely distances people and goods need to travel. Research
health boards in the UK. populated health boards in the UK (Figure 1). suggests that people in rural areas spend £100 per
3. There are specific geographic The COVID-19 pandemic has exacerbated the month more on fuel than people living in urban
and demographic challenges,
challenges for delivering healthcare in the region, areas (Scottish Government, 2018b). There is also a
compounded by staff
capacity, to ensuring equity with some particular problems being the restricted significant lack of transport infrastructure.
of access for people living ability to travel for both patients and healthcare
with diabetes to podiatry
professionals, patients and healthcare professionals Connectivity
services in rural communities.
who were shielding, the demographic profile and the Connectivity remains a barrier to optimal
2. COVID-19 encouraged the
podiatry and multidisciplinary restricted service provision. communication in rural areas, with 4G indoor
diabetes foot teams to coverage in 81% of households Scotland-wide,
innovate and advance the Background and challenges but only 56–70% in rural areas and 42% access to
service delivery options.
Population gigabit broadband, falling to 13% in rural areas.
4. A well-developed virtual
approach should be attainable, The population of the North and South Highland Overall, 17% of rural households do not have access
with innovations to team- health board area is around 345,382. The Highland to decent broadband (Ofcom, 2020).
building, service redesign Council area has experienced a 13% population
and education delivery.
increase in the last 20 years, with a 55% increase Diabetes
in people aged 65–74 years and a 63% increase in NHS Highland has a diabetes population of 19,532
those aged ≥75 years, compared with 30% and 34% (NHS Scotland, 2019). In terms of type of diabetes,
for Scotland as a whole, respectively. Numbers for 88% have type 2, with age being a major risk factor.
the ≥75 age group are projected to increase by 34% This is reflected in the crude prevalence of diabetes
within the next 10 years. Life expectancy is also in Highland region at 5.8% adjusted to 5.1%. In
Authors higher than the Scottish average (National Records Highland, prevalence of diabetes increases to 14.4%
Details on p2 of Scotland, 2019). in those over 65 years of age (NHS Scotland, 2019).
1 The Diabetic Foot Journal Vol 24 No 2 2021
Future-proofing diabetes foot services in remote and rural health settings post COVID-19
Figure 1. Scottish terrestrial health board regions, with Figure 2. The Scottish Government’s classification
NHS Highland in dark purple. highlights the remote rural nature of NHS Highland.
In addition, prevalence is higher in regions at a 107 practices in Scotland, with five of those within
significant distance from the specialist centre; for the NHS Highland region (College of Podiatry,
example, the largest practice in the far north of the 2021). The authors acknowledge there are other
Highland Health Board region has a prevalence of professional bodies where private practices may
6.2%, compared with 4.9% in the largest Inverness be registered.
city practice (SCI-Diabetes, 2021). Staffing levels have not improved during
COVID-19 with staff on long-term sick leave and
Staffing redeployment, and a range of vacant podiatry posts.
Shortly before the COVID-19 pandemic struck, a How do we work together to have a positive impact
comparison was undertaken of podiatry staffing per on the outcomes for patients and service users? With
head of population within several Scottish Health people living longer, we need to adapt and find new
Boards (Stewart and Wells, 2019). NHS Highland ways to support people living with complex health
figures show the lowest whole time equivalent per and care needs, including empowering communities
head of population per square kilometre (Table 1). to offer local support. We also need to work with
Using the formula of staff per 1,000 patients is not partners to support the workforce into the future
appropriate to determine how many podiatrists (NHS Highland, 2013; College of Podiatry,
are required for safe and effective practice, even 2017). Partnerships between health, education and
with improved technology; no account is taken professional bodies must be continued to support
Authors
of variables such as travel distance and time, the workforce into the future.
Sandra Jones is Diabetes Specialist
practitioners’ skill set and access to facilities. Stewart Podiatrist and Podiatry Diabetes
and Wells made no reference to any private podiatric Overcoming challenges Co-ordinator, NHS Highland,
Scotland, UK; Sandra MacRury
practice network availability. New pathways
is Consultant Diabetologist,
A search for private podiatric practitioners Podiatrists are adept at keeping populations mobile Raigmore Hospital, Inverness,
registered with the College of Podiatry revealed and active and also at preventing conditions from NHS Highland, Scotland, UK
The Diabetic Foot Journal Vol 24 No 2 2021 2Future-proofing diabetes foot services in remote and rural health settings post COVID-19
Table 1. Whole time equivalent NHS podiatric staff in five Scottish health board areas with NHS Highland split
into three distinct regions (Stewart and Wells, 2019).
Area NHS podiatric staffing NHS podiatric staff per P-value
establishment head of population
North and West Highland (Caithness and 10.6 WTE 118,789 = 1 podiatrist to 0.152
Sutherland; Lochaber and Skye; and Lochalsh 11,206
and Wester Ross)
South and Mid Highland (Inverness, Badenoch 13.3 WTE 141,188 = 1 podiatrist to 0.774
and Strathspey; Nairn, Mid Ross and Easter 10,944
Ross)
Argyll and Bute Highland (Oban, Lorne and 11.7 WTE 85,405 = 1 podiatrist to 0.165
the Isles; Mid Argyll, Kintyre and the Islands; 7,230
Cowal and Bute; and Helensburgh and
Lomond) (6,905 km2)
Greater Glasgow and Clyde 161.5 WTE 1,137,970 = 1 podiatrist to 0.984
7,046
Dumfries & Galloway (642.6 km2) 24.0 WTE 148,790 = 1 podiatrist to 0.485
6,199
Shetland (1,468.5 km2) 3.6 WTE 24,000 = 1 podiatrist to 0.379
6,666
Western Isles (3,056 km2) 6.6 WTE 27,500 = 1 podiatrist to 0.064
4,154
WTE = whole time equivalent
deteriorating (College of Podiatry, 2017). Podiatrists consultations. NHS Highland e-health department
as first contact practitioners are being promoted worked incredibly hard to ensure IT hardware
by the College of Podiatry (2020). Through its was enabled to work securely and safely from
Vascular Infection Pressure (VIP) pathway, NHS home where necessary. Clinicians had to adapt to
Highland has been advising podiatry as first point and learn new systems to enable them to become
of contact for all high-risk/active foot disease proficient in transforming consultations and
patients since 2019. communication methods.
Since COVID-19 hit early in the roll-out process Contact was made with our multidisciplinary
of the VIP pathway, it was necessary to reconsider team (MDT) utilising e-clinic facilities for
how the first point of contact might look. Patients patients with high-risk severity for limb loss
continued to self-refer; electronic referrals tended (severe infection or severe ischaemia). Patients
to come from other healthcare professionals to with moderate risk severity for limb loss (infection
several locations in the region; triaging happened or ischaemia) are treated in outpatient facilities
in a timely manner in community/primary care where possible and homecare services are planned.
settings, particularly where podiatry colleagues were Patients with less severe lesions (no infection) are
shielding and/or working from home and could given a telemedicine contact with pictures and/
telephone patients. or video call, including caregivers or family if
The lower-limb amputation prevention guidance necessary. Generic email addresses have been used
from Foot in Diabetes UK (2020) supported the in each locality to allow contact to be made with
VIP pathway. This allowed us to triage whether podiatry services; photographs have been emailed
a face-to-face appointment was needed or if a to the service as part of an agreed care plan with
phone or video consultation was suitable. Video patients/carers/families.
appointments are via the NearMe consultation There are practitioners working remotely
(https://www.nearme.scot). and rurally, at a distance from specialist multi-
Many remote and rural centres were not well disciplinary centres, who have advanced practice
equipped to deal with the rapid changes that knowledge and skill and, through this pathway,
were required to deal with the changing face of become an integral member of the specialist MDT.
3 The Diabetic Foot Journal Vol 24 No 2 2021Future-proofing diabetes foot services in remote and rural health settings post COVID-19
Technology Optional for network access
A particular example in Highland of how the ‘Direct Access Software’
SCI Store / SCI Diabetes / Trakcare
technology advances described above can be utilised
and encompass the principle of a unified generalist/
specialist podiatry approach in a widely distributed Video consultation
from patient’s home
rural area was the Reducing Amputations In
Diabetes (RAPID) project (MacRury et al, 2018;
Main et al 2021). Briefly, this technology-enabled
care (TEC) approach was trialled over several phases
iFi
to optimise it. A new service pathway was developed a lW
Loc
based on a triage system for notification of diabetes
foot ulceration to the specialist team, and decision
support with options for a home video conferencing
consultation with the diabetes foot MDT facilitated Omni-router Mini™ device
Battery operated Tablet used for video consultation
Specialist Diabetes team member
by the community podiatry team. The service Prioritisation cellular networks with patient in their home
evaluated well, improved skill level in the generalist
podiatry team and raised the potential for cost savings RAPID pathway
in the management of diabetic foot ulceration and
amputations, with early intervention and access to the Patient with diabetes •Community podiatrist Generic foot
email account
foot ulcer at home in •Community Nurse
diabetes MDT service. rural community
•GP
REFERRAL Proforma with
New/Static/Deteriorating background
Implementing non-hospital care across our vast •Any Health Care Professional information &
area requires a well-established network of individual •Any stage of foot ulcer images
clinicians working together with agreed-upon referral REVIEW
arrangements (in person or via telemedicine). NHS
Highland Podiatry Service has been fortunate in
Email advice +/-
that there is such a network within the four localities •Wound review appointment arranged with Mailbox checked
Community Nurse or Podiatrist Monday-Friday (working
— Argyll and Bute, Caithness and Sutherland, •Home or Community Clinic VC NHS Near hours) excluding public
OUTCOME holidays
Skye and Lochaber and Lochalsh, and South and Me consultation with HCP in attendance
•Face-to-face Diabetes Foot Clinic
Mid Highland. •Further investigation required/follow-up Referrals triaged within
24 hours by Diabetes
consultant clinic
There has been a stable workforce for several years; •Ongoing follow-up Community Specialist Podiatrist
however, we are reaching a point now where highly Podiatrist/Nurse/DSP
skilled and experienced practitioners are retiring
from the service and from the profession. There Figure 3. The Highland service pathway.
are also very strong working links with care homes,
community nursing and practice nursing. Shared care video consultations, even in urban areas (Exposito
of patients features highly in remote and rural areas, et al, 2020). The main advantages have been
and we and the patients rely on that inter-dependence. reduction in travel for staff and patients, improved
Workforce planning and workforce capability is staff efficiency and cost savings.
going to play a significant part in NHS Highland A high satisfaction level was reported by patients
Podiatry Service delivery with the right people at the with the service pathway and technology, at 99%
right time in the right place. and 96% respectively (Main et al, 2021). The model
can be extended to the ‘hospital-at-home’ approach,
The future with new paradigms such as the Highland RAPID
Technology-enabled care and learning programme currently being rolled out in both north
Virtual consultations are here to stay. The major and south Highland as a service pathway to support
shift seen in the use of video conferencing has been all of our rural communities initially (Figure 3). There
reflected across healthcare delivery nationally and is also the opportunity to extend it to urban areas and
internationally. In general podiatry, practice has explore its use in other podiatry services, non-podiatry
witnessed large changes in the use and acceptance of disciplines and outside the region.
The Diabetic Foot Journal Vol 24 No 2 2021 4Future-proofing diabetes foot services in remote and rural health settings post COVID-19
Despite the traditional ‘hands on’ approach to The workforce requirements and capabilities
podiatry services, the technology revolution will can be measured and developed by applying the
complement and enhance practice through both Capability Framework for Integrated Diabetic
TEC and technology-enabled learning (TEL). Lower Limb Care in assessing individual and
Telemedicine will underpin changes in practice team requirements (Short-life Working Group,
already implemented during COVID-19, with 2019). As highlighted, community practitioners
the caveat that upscaling of platforms, education work remotely and rurally and have advanced
and knowledge need to include guidance practice knowledge and skill. A second useful
and — importantly — governance for the resource for developing clinicians is the NHS
workforce using TEC (Chadwick et al, 2020). Education for Scotland (2021) Multidisciplinary
The use of smart wearables and other telehealth Rural Advanced Practice Capabilities Framework
technologies, such as cameras, sensory and Primary and Community Care, in particular
heat detection devices, robotics and artificial Capability 6: Collaborative working to provide
intelligence, will aid remote monitoring and evidence based, quality assured, person-centred
will maximise the workforce value (Health care enabling self-management and wellbeing
Education England, 2019). throughout the care journey.
TEL incorporating elements of virtual In addition, working with the College of
and simulated learning will allow for a wide Podiatry, we are exploring innovations for
geographical and equitable distribution for reskilling, for example, through foundation or
training and supporting a range of healthcare graduate apprenticeships which will complement
professionals, and other workers in remote and our skills base and ensure an agile and capable
rural areas. workforce going forward.
However, connectivity remains a barrier
to optimal TEC and TEL in rural areas. The Conclusion
Scottish Rural Network programme is working There are specific geographic and demographic
with the Scottish Government and the Scottish challenges, compounded by staff capacity,
4G Infill Programme to expand coverage. to ensuring equity of access for people living
Satellite may offer a potential solution, although with diabetes to podiatry services in rural
mobile access is expensive. We are exploring communities. However, a well-developed virtual
the use of fixed satellite for service delivery approach should be attainable, and alongside
in key spots with remote general practitioner or complemented by with innovations to
premises in Highland. team building, service redesign and education
delivery will allow staff to utilise their skills to
Team working the full extent, while enjoying the benefits of
The formalising of locality MDTs, led by and fulfilment that working in one of the most
organisational change, should ensure the patient beautiful rural areas in the UK has to offer. n
experience is optimised, and is patient-centred in
all aspects. Scottish Care Information Diabetes Chadwick P, Ambrose L, Barrow R, Fox M (2020) A
commentary on podiatry during the Covid-19 pandemic. J
(SCI Diabetes), a multidisciplinary patient Foot Ankle Res 13(1): 63
College of Podiatry (2017) Podiatry: Driving Value, improving
record, will ensure optimal communication outcomes. College of Podiatry, London
within the diabetes team, including the patient, College of Podiatry (2020) Podiatrists as First Contact
Practitioners. Available from: https://cop.org.uk/api/
who is central to the team. documentlibrary/download?documentId=411 (accessed
MyDiabetesMyWay is the NHS Scotland 15.06.2021)
College of Podiatry (2021) https://cop.org.uk/find-a-
interactive diabetes website to help support podiatrist#FIND.PODIATRIST (accessed 07.05.2021)
Exposito C, Allan F, Greenwood N et al (2020) COVID-19 as
people who have diabetes and their family and a catalyst for change: virtual foot protection. The Diabetic
friends; patients can sign up to gain access Foot Journal 23(3): 36–44
Foot in Diabetes UK (2020) COVID-19 Situation v1.3: Limb
to their own test results, clinic letters and Amputation Prevention Guidance. Available from: https://
w w w.wounds-uk.com /resources /det ails / lower-limb -
treatment plans (https://www.mydiabetesmyway. amputation-prevention-guidance (accessed 15.06.21)
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